Silent Suffering: Maternal Morbidities in Developing Countries

Maternal morbidities – illnesses and injuries that do not kill but nevertheless seriously affect a woman’s health – are a critical, yet frequently neglected, dimension of safe motherhood. For every woman who dies, many more are affected acutely or chronically by morbidities, said Karen Hardee, president of Hardee Associates at the Global Health Initiative’s September 27 panel discussion, “Silent Suffering: Maternal Morbidities in Developing Countries.” Hardee was joined by Karen Beattie, project director for fistula care at EngenderHealth, and Marge Koblinsky, senior technical advisor at John Snow, Inc., for a discussion moderated by Ann Blanc, director of EngenderHealth’s Maternal Health Task Force.

Obstetric fistula – a hole or tear that connects the vagina to either the bladder or rectum – is caused by prolonged, obstructed labor without timely medical intervention. Although solid prevalence data is lacking, Karen Beattie estimated that there are two million cases worldwide and 50,000 to 100,000 new cases each year.

Obstetric fistula is a question of equity, Beattie said, and a “clear example of a health system’s failure to support women’s needs in childbirth. …Women with fistula are most often the most impoverished and vulnerable members of society.” EngenderHealth found, for example, that delays in care in Tanzania were due not so much to geography but rather lack of money for services and lack of transportation.

Obstetric Complications Affect 20 Million Women

A study on maternal morbidity in Bangladesh, carried out by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), determined that seven percent of women who delivered in a facility suffered a severe obstetric complication. More than 60 percent of these complications were due to dystocia, or severe obstructed labor, according to Marge Koblinsky. Furthermore, approximately 40% of all women suffered some kind of postpartum problem.

Maternal mortality is just the “tip of the iceberg,” according to Koblinsky. The study found that for every maternal death, approximately 38 women suffer obstetric complications – equivalent to an estimated 20 million women worldwide. Furthermore, the level of neonatal deaths was five times higher among women who had suffered a complication, even up to two years post-delivery.

The economic cost for the families of women who had suffered an obstetric complication was very high. The poorest quintile of the study sample spent as much as 35 percent of their annual income to pay for treatment, said Koblinsky. Obstetric complications and their consequences also resulted in negative social outcomes for the women and their families, including stigma, verbal abuse, domestic violence, divorce, and isolation.

Prevention, Follow-Up Are Key

In order to adequately address maternal morbidities, health experts need to know where programs that reduce mortality will also reduce morbidity, and where additional programs are needed, said Hardee. However, this analysis requires more accurate estimates of incidence, prevalence, and cost data.

In the case of obstetric fistula, the focus should be on prevention, said Beattie. Other key interventions include providing access to family planning, using a partograph correctly and consistently, catheterizing the mother immediately after prolonged or obstructed labor, and increasing access to emergency obstetric care. More resources for training and service provision are also critical.

The Bangladesh study recommended postpartum follow-up for up to a year, financial protection for the poorest women, and family counseling, particularly in the case of a child’s death. “Perinatal death has a huge impact on the woman,” said Koblinsky. However, “it’s not just the woman; it’s the family that needs the counseling, for her postpartum depression, but also to alleviate the domestic violence that can ensue, as well as the social impact.”

Furthermore, programs should “address the antecedents of poor maternal health,” said Hardee, including nutrition, sanitation, education, and gender-based violence, as well as the silence surrounding women’s birth experiences. We must “shatter that gender norm and have women actually talk about these things,” Hardee concluded.